英华外语学校临床医学英语第45.38.49章.pdf

青岛英华外语学校http:/青岛英华外语学校http:/Chapter 45Acute Abodomen-Decision to OperateThese difficulties notwithstanding,the surgeon must make a decision tooperate or not.Certain indications for surgical treatment exist.Notwithstanding尽管虽然尽管有这些困难，外科医生必须作出是否手术的选择。有一些外科手术的指征。For example,definite signs of peritonitis such as tenderness,guarding,andrebound tenderness support the decision to operate.Peritonitis 腹膜炎比如说，特定的腹膜炎体征如腹痛，肌卫，反跳痛都支持手术的决定。Likewise，severe or increasing localized abdominal tenderness should promptan operation.同样的，严重的或者逐渐加重的局限性腹痛也应马上手术。Patients with abdominal pain and signs of sepsis that cannot be explainedby any other finding should undergo operation.无法解释的腹痛伴随脓毒症的病人应该进行手术。Those patients suspected of having acute intestinal ischemia should beoperated on after complete evalution.对怀疑肠缺血的病人需进行充分评估后手术。Certainradiogragphic findings confidently predict the need for operation.某些诊断学的发现比较确切地提示了手术指证。Thesefindingincludepneumoperitoneumandradiologicevidenceofgastrointestinal perforation这些发现包括气腹证或者胃肠穿孔的放射学证据。Patients presenting with abdominal pain and free intra-abodominal gas seenon radiograph warrant operation with limited exceptions.如果患者有腹痛并且 X 光片上有腹腔内气体，绝大部分病人需要手术。Observation with serial examinations may be appropriate for a patient withfree gas after a colonoscopy.结肠镜检查后出现自由气体的病人需要观察并做一系列的检查。Intra-abdominal gas can persist for a day or two following celiotomy.剖腹术后腹腔内气体还可以遗留一至二天。Imaging tests can reveal signs of vascular occlusion requiring operation.放射学检查可以提示需要手术的血管阻塞疾病。After careful examination and evaluation,diagnostic uncertainty can remain.Some patients may have equivocal physical findings.详细的检查和评估之后，诊断未明确的可以继续观察。一些病人可能表现出模棱两可的体征。When this occurs and the diagnosis is unclear and the patients wellness isunclear,it may be advisable to defer operation and to re-examine the patientcarefully after several hours.如果有上述情况，诊断不明确，病人症状无好转，建议延期手术，数小时后再次详青岛英华外语学校http:/青岛英华外语学校http:/细检查。This is best done in a short-stay unit in the hospital,in a specialunit in the emergency department,or if necessary,by regular hospitaladmission.最好能在医院短期留观或者在急诊室观察，如果有必要可以入院观察。In a period of hours,vague pain with minimal physical findings may proceedto definite localized pain with tenderness,guarding,and rebound tenderness;if that occurs,operation should follow如果在数小时内，没有明显体征的腹胀转化为明确的局限性腹痛，肌卫和反跳痛，则手术指证明显。After severalhours,the patients symptoms and signs may also resolve.也有可能，数小时后病人的症状和体征消失。When that happens,the patient can be dismissed,although the patient shouldhave a follow-up appointment scheduled within a day or so to permitre-examination to be certain that an important diagnosis was not missed.如果是这种情况，病人可以出院，虽然仍需短期的随访和重新检查，以免遗漏重要的诊断。Certainpatientsaredifficulttoevaluatebecauseofspecialcharacteristics.有些病人由于特殊性很难评估。For example,patients who are neurologically impaired as result of strokeor a spinal cord injury may be difficult to evaluate.如由于中风或脊髓损伤导致的神经系统功能不全的病人。Patients who are under the influence of drugs or alcohol may require specialor subsequent examination.受药物（毒品）或酒精影响的病人需要进行特殊或者后续进一步检查。Patients who take steroids or are otherwise immunosuppressed deserve specialmention because steroids and immunosuppression mask the intensity ofabdominal pain and the physical findings of severe,life-threateningintra-abdominal disease.服用类固醇或免疫抑制剂的病人需要特别注意，因为类固醇和免疫抑制剂能掩盖腹痛的程度及严重致命的腹腔疾病。Patients in this category who have persistent,unequivocal abdominal painand even minimal findings should be considered for surgical operation.unequivocal 明确的，不模棱两可的此类病人如果有持续性，明确的腹痛，甚至轻微的腹痛也应该手术。Some patients with clear findings of the acute abdomen may be treated withoutsurgical operation有些病人即使有明确的急腹症也可以不需要手术。For example,patients with perforated duodenal ulcer who seek attention latein the course of their disease after they have been sick for several daysmay be treated best by careful supportive care including nasogastric suction,intravenous fluids,and pain relief.如十二指肠溃疡穿孔病人，病人已有多天，而发作也很迟，最好进行支持性治疗，如胃肠减压，静脉输液和止痛。青岛英华外语学校http:/青岛英华外语学校http:/Certain patients with empyema 积脓 of the gallbladder,especially those withother serious concomitant 伴随的 illnesses,can be treated by percutaneousdrainage of the infected gallbladder and careful supportive care rather thanwith cholecystectomy.对于胆囊积脓患者，尤其是伴有其他严重疾病，宁可选择经皮引流和支持疗法，而不进行胆囊切除术。Chapter 36 Endoscopic ultrasonograhy本篇篇名为内镜超声检查（或称超声内镜）。在疾病诊治上，超生内镜作为一种检查和治疗的新技术在临床上逐渐得以应用，与传统的诊治方法比较，它具有一定的优势。本篇主要介绍内镜超声检查的基本情况、与传统方法比较以及它在临床诊治方面的优势所在。The development of endoscopic ultrasonography(EUS),or endosonography,hasbeen a major technological achievement in gastroenterology.Gastroenterology 胃肠学achievement 成就胃肠内镜的发展是胃肠学上重大的技术成就。The incorporation of an ultrasonic transducer in tip of a flexible endoscopeor the use of stand-alone ultrasound probes has now made it possible to obtainimages of gastrointestinal lesions that are not apparent on superficial views,including lesions within the wall of the gut as well those that liebeyond(e.g.,pancreatic or lymph node lesions)。Incorporation 并入，掺合Transducer 超声换能器青岛英华外语学校http:/青岛英华外语学校http:/Superficial 表面的，浅表的Gut 肠道的Flexible 柔软的，易曲的将超声换能器并入内镜的头部或仅仅使用超声探头就现在就可以获得无法从浅表探测到的胃肠疾病的影像,包括肠壁内或这肠表面(如胰腺疾病或淋巴结病变）。A further role of EUS is to guide fine-needle aspiration,which often providespathologic confirmation of suspicious lesions.超声内镜另外被用作细针穿刺的引导，可以对可疑的病灶进行病理学的确诊。Inmany cases,this approach appears to be even more accurate than conventionalradiologic techniques such abdominal ultrasonography or CT.Conventional 常规的，一般的Approach 方法在许多病例中，这种方法比常规的放射学检查如腹部超声、CT 更精确。Thus,EUS is probably the single best test for diagnosing pancreatic tumors,particularly the small endocrine varieties,with sensitivities approaching95%.因此，EUS 可能是最好的胰腺肿瘤诊断方法，尤其对小的内分泌肿瘤，灵敏度可达95。It is also the procedure of choice for imaging submucosal and other walllesions of the gastrointestinal tract(overall accuracy of 65 to 70%)as wellas for staging of a variety of gastrointestinal tumors(overall accuracy of90%or more).Submucosa 粘膜下层的EUS 同时是粘膜下层和其他胃肠道壁疾病的常规检查方法（总体准确率为 65到 70），也是很多胃肠道肿瘤分期的方法（总体准确率超过 90）Preoperative staging is a critical element in the management strategy fortumors such as esophageal and pancreatic cancer,肿瘤治疗的术前分期是非常关键的因素，尤其对食道癌和胰腺癌。EUS can complement more conventional radiologic tests to help determine theresectability and curative potential of surgery in these cases.Complement 补足，补充Conventional 常规的，惯例的，一般的EUS 可以弥补常规的放射学检查方法来确定外科切除和治疗的可能性。In addition to its valuable diagnostic role,EUS is rapidly emerging astherapeutic tool.除了其有价值的诊断作用，EUS 正快速地成为治疗工具。One example is EUS-diercted celiac plexus neurolysis,a technique thatappears to effective for the treatment of pain in patients with pancreaticcancer.celiac plexus 腹腔丛Neurolysis 神经松紧术其中一个例子就是采取 EUS 导向的腹腔丛神经松紧术治疗胰腺癌所导致的疼痛。Unfortunately,this approach does not appear to work as well in patients withchronic pancreatitis.青岛英华外语学校http:/青岛英华外语学校http:/不幸的是，这个治疗方法好像对慢性胰腺炎疗效不佳。Chapter 54 Benefit of Early enteral feeding versusparenteral nutrition本篇篇名为早期肠内与肠外营养的优点比较。病人的营养供给是必需的，但选择的途径可以有所不同，如肠内营养或肠外营养。比较而言，这两种营养均比较安全。本篇主要对一些病人的早期营养与肠外营养进行比较，结果提示，早期场内营养在降低感染和减少住院时间等方面有优势。It is often said that enteral nutrition is safer and more efficacious thanthe parenteral route.人们通常认为肠内营养比肠外营养更安全,更有效.但这一观点并没有在早期的动物实验和临床研究中得到承认However a preliminary note of caution is raised from observations inexperimentalanimals,whichconcludedthatoutcomesofenteralandparentaeral nutrition were equivalent when animals with catheter sepsis wereeliminated.但是动物实验观察得到的初部结果告诉我们当导管脓毒症消除以后，肠内和肠外营青岛英华外语学校http:/青岛英华外语学校http:/养结果是类似的。Numerous studies have shown that it is safe to feed the gut in the immediatepostoperative period and that this practice does not place the integrity ofintestinal anastomoses at risk.为数众多的研究标明术后即刻的肠内营养是安全的，同时对肠吻合口也不会带来风险。Early feeding has been studied primarily in two patient populations:thosewho have undergone gastrointestinal surgery and in traumatically injured orcritically ill persons.早期进食实验最初是在两组实验病人中进行：一组是为胃肠术后病人，另一组为创伤或危重病人。A recent meta-analysis reviewed 11 prospective,randomized,controlledtrails that compared the practice of early enteral feeding to maintainingpatients NPO after elective gastrointestinal surgery.最近的一项 meta 分析对 11 个随机分组前瞻性研究来对照择期胃肠术后早期肠内营养与禁食病人。This analysis of 837 patients concluded that there is no clear advantage tokeeping patients NPO postoperatively and that early feeding may be of benefitin decreasing infections and shortening postoperative length of stay.对837 位病人的研究标明术后禁食病人（比早期肠内营养）没有明显益处，而且早期进食可以降低感染率，缩短住院时间。However,a closer evaluation of this data reveals that the length of staywas reduced only by 0.84 day,and although there was an increase in“anytype of infection”in the NPO group,when considered individually,therewas no difference in the incidence of anastomotic dehiscence,woundinfections,pneumonia,intra-abdominal abscess,or mortality.但是，另一项相近的研究认为禁食组病人虽然住院时间缩短了 0.84 天，但“感染”发生率提高了，个别进行分析的结果表明，吻和口瘘，切口感染，肺炎，腹内脓肿及死亡率（两组间）没有差别。In 2001 Marik and Zaloga performed a meta-analysis of 15 randomized,controlled trails involving 753 subjects that compared early with delayedenteral nutrition in critically ill surgical patients.Early enteralnutrition was associated with a significantly lower incidence of infection(relative risk reduction of 0.45)and reduced length of hospital stay(2.2days less).2001 年 Marik 和 Zaloga 对 15 组 753 例危重外科病人进行了 meta 分析以比较早期和晚期肠内营养的疗效。早期肠内营养组感染发生率明显较低（相对风险降低0.45），住院日也有减少（少 2.2 天）。There were no differences in noninfectious complications or in mortality.The authors concluded that early initiation of enteral feeding was beneficial,but this result must be interpreted with caution because of substantialheterogeneity between studies.非感染性并发症和死亡率无明显差别。作者认为早期肠内营养是有益的，但是考虑到研究中的差异性，这个结果需要谨慎对待青岛英华外语学校http:/青岛英华外语学校http:/The studies that compared enteral and parenteral nutrition in the traumapopulation,as discussed earlier,concluded that enteral was superiorbecause of an attenuated inflammatory response and a decrease in septicmorbidity.Attenuated 衰减，减弱Inflammatory 炎症性septic morbidity败血症发病率由于感染率和败血症发病率低，正如先前所进行的创伤病人有关肠内和肠外营养的结果得出，肠内营养超过肠外营养。When these studies are examined more closely,it is clear that patients whowere fed enterally usually received significantly less calories than thosefed parenterally.经过严密的研究发现肠内营养的病人吸收的热量明显少于肠外营养病人。This discrepancy of“relative overfeeding”in the TPN groups in manyinstances led to hyperglycemia,presumably predisposing patients to immunedysfunction and nosocomial infection.Discrepancy 不一致，偏差Hyperglycemia 高血糖症nosocomial infection 院内感染Predispose 成为因素TPN 组相对营养过度使许多病人产生高血糖症，据推测可以导致免疫功能下降和院内感染。Thus,poor glucose control alone may account for the observed differencesin outcome.account for 说明，解释因此，血糖控制不佳可以解释说观察到的结果的差异。In more contemporary studies where feeds are carefully advanced in a mannerthat avoids hyperglycemia and groups are fed equivalent protein and calories,there appears to be little difference in clinical outcome between enteraland parenteral routes of feeding.Contemporary 当代的，同代的Equivalent 相当的，相等的当代的研究发现，如果肠外营养经过改进避免高血糖的可能，给予与肠内营养相似的蛋白质和热量，两组之间的预后差异不大。Enteral nutrition also can endanger patient safety in unique ways.Endanger 使危险，危及Unique 独特的肠内营养也可以危及病人的安危。Deaths in persons receiving enteral nutrition are often due to aspiration,for example when gastric motility suddenly is impaired with the onset ofsepsisAspiration 误吸gastric motility肠内营养病人的死亡常常是由于误吸，如由于败血症的发生说导致的胃能动性的损青岛英华外语学校http:/青岛英华外语学校http:/伤。One death from aspiration is equivalent to the mortality over 2 to 3 yearsof well-operated parenteral nutrition program,despite the danger ofcatheter sepsis,which in well-operated units is now less than 1%to 3%.equivalent 相当的，相等的catheter sepsis 导管脓毒症除了导管脓毒症的危险以外，通常在管理良好的单位发病率低于 1至 3，误吸的死亡率与实行了 23 年良好管理的肠外营养病人相当。